Vaginal Cutting During Childbirth Is on the Decline

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It is becoming less common for doctors in the U.S. to make
incisions in a woman's vagina and pelvic floor muscles during
childbirth, in the wake of 2006 recommendations against the
procedure, new research finds.

Episiotomies, deliberate cuts in the perineum, which is the
tissue between the vagina and the anus, were once standard
practice during vaginal
deliveries. Doctors believed the procedure eased childbirth,
and allowed women's bodies to heal better than after natural
tears, but those benefits weren't borne out. In fact, studies
suggest that episiotomies are often more severe than natural
tears and that they can be linked to anal incontinence and future
pain during sex, according to the American College of
Obstetricians and Gynecologists (ACOG).

ACOG recommended against routine episiotomies in 2006.

"As a result, doctors and midwives are using the procedure less
frequently," said Dr. Alexander Friedman, an OB-GYN at Columbia
University Medical Center in New York, who led the new study.

In the 1970s, more than 60 percent of vaginal births were
accompanied by an episiotomy, a number that had already declined
to about 25 percent by 2004. But no one had studied whether
episiotomies continued to decrease after the new recommendations
came out. Friedman and his colleagues looked at data in the
Perspective insurance database, which records billings for
medical procedures at more than 500 hospitals nationwide. They
gathered records of episiotomies that were done as a matter of
routine, excluding cases of difficult deliveries where the doctor
might have no choice but to cut.

Between 2006 and 2012, the researchers found, nearly 2.3 million
women gave
birth vaginally at these 510 U.S. hospitals. Of these, about
325,000 had episiotomies — a total of 14.4 percent. And, the
researchers found, use of the procedure declined over time. In
2006, 17.3 percent of vaginal births involved episiotomies. In
2012, the number dropped to 11.6 percent.

There was, however, wide variation among hospitals. At the
facilities that used episiotomies the most, 34 percent of women
underwent the procedure, compared with 2.5 percent of women at
hospitals with the fewest episiotomies.

Nonmedical choices?

The researchers noted that some factors not related to medicine
played a role in the differences in the episiotomy rate across
hospitals. For example, rural hospitals performed fewer
episiotomies than urban ones, and teaching hospitals used fewer
episiotomies than non-teaching hospitals. They also found that
white women were almost twice as likely to undergo the
procedure as black women (15.7 percent versus 7.9 percent in the
database). And insurance coverage seemed to have some influence:
17.2 percent of women using commercial health insurance got
episiotomies, versus 11.2 percent using Medicaid.

"Our data — particularly the variation between hospitals — does
suggest that episiotomy use could be further reduced by improving
care quality," Friedman said.

There is no known "right" level of episiotomy use, he said, but
hospitals should consider examining their own rates to see if
they fall on the high end.

"If they have particularly high rates, they should try to figure
out why that is happening and work to educate their staff about
appropriate use," Friedman said.